H1N1 severity: One in 70 cases estimated to result in hospital admission

Every winter, millions of people catch influenza "a viral infection of the airways” and about half a million people die as a result. In the U.S. alone, an average of 36,000 people are thought to die from influenza-related causes every year.

These seasonal epidemics occur because small but frequent changes in the virus mean that an immune response produced one year provides only partial protection against influenza the next year. Occasionally, influenza viruses emerge that are very different and to which human populations have virtually no immunity. These viruses can start global epidemics (pandemics) that kill millions of people. Experts have been warning for some time that an influenza pandemic is long overdue and in, March 2009, the first cases of influenza caused by a new virus called pandemic (H1N1) 2009 (pH1N1; swine flu) occurred in Mexico.

The virus spread rapidly and on 11 June 2009, the World Health Organization declared that a global pandemic of pH1N1 influenza was underway. By the beginning of November, 2009, more than 6,000 people had died from pH1N1 influenza.

With the onset of autumn â€” drier weather and the return of children to school help the influenza virus to spread â€” pH1N1 cases, hospitalizations, and deaths in the Northern Hemisphere have greatly increased. Although public-health officials have been preparing for this resurgence of infection, they cannot be sure of its impact on human health without knowing more about the severity of pH1N1 infections.

The severity of an infection can be expressed as a case-fatality ratio (CFR; the proportion of cases that result in death), as a case-hospitalization ratio (CHR; the proportion of cases that result in hospitalization), and as a case-intensive care ratio (CIR; the proportion of cases that require treatment in an intensive care unit).

Because so many people have been infected with pH1N1 since it emerged, the numbers of cases and deaths caused by pH1N1 infection are not known accurately so these ratios cannot be easily calculated.

In this study, the researchers estimate the severity of pH1N1 influenza in the U.S. between April and July 2009 by combining data on pH1N1 infections from several sources using a statistical approach known as Bayesian evidence synthesis.

By using data on medically attended and hospitalized cases of pH1N1 infection in Milwaukee and information from New York City on hospitalizations, intensive care use, and deaths, the researchers estimate that the proportion of U.S. cases with symptoms that died (the sCFR) during summer 2009 was 0.048%. That is, about 1 in 2,000 people who had symptoms of pH1N1 infection died. The “credible interval” for this sCFR, the range of values between which the “true” sCFR is likely to lie, they report, is 0.026%–0.096% (between 1 in 4,000 and 1 in 1,000 deaths for every symptomatic case).

About 1 in 400 symptomatic cases required treatment in intensive care, they estimate, and about 1 in 70 symptomatic cases required hospital admission. When the researchers used a different approach to estimate the total number of symptomatic cases based on New Yorkers' self-reported incidence of influenza-like-illness from a telephone survey, their estimates of pH1N1 infection severity were 7- to 9-fold lower.

Finally, they report that the sCFR and the sCIR were highest in people aged 18 or older and lowest in children aged 5-17 years.

Many uncertainties (for example, imperfect detection and reporting) can affect estimates of influenza severity. Even so, the findings of this study suggest that an autumn–winter pandemic wave of pH1N1 will have a death toll only slightly higher than or considerably lower than that caused by seasonal influenza in an average year, provided pH1N1 continues to behave as it did during the summer. Similarly, the estimated burden on hospitals and intensive care facilities ranges from somewhat higher than in a normal influenza season to considerably lower.

The findings of this study also suggest that, unlike seasonal influenza, which kills mainly elderly adults, a high proportion of deaths from pH1N1infection will occur in nonelderly adults, a shift in age distribution that has been seen in previous pandemics. With these estimates in hand and with continued close monitoring of the pandemic, public-health officials should now be in a better position to plan effective strategies to deal with the pH1N1 pandemic.

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